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Aydın et al. Fetal ventriculomegaly 141
J Clin Exp Invest www.jceionline.org Vol 4, No 2, June 2013
1 Zeynep Kamil Kadın Doğum ve Çocuk Hastalıkları Eğim ve Araşrma Hastanesi Perinatoloji, İstanbul
2 Mehmet Akif Ersoy Eğim ve Araşrma Hastanesi Çocuk Kardiyoloji Kliniği, İstanbul
3 Batman Kadın Doğum ve Çocuk Hastalıkları Hastanesi Kadın Hastalıkları ve Doğum Bölümü, Batman
4 Dicle Üniversitesi Kadın Hastalıkları ve Doğum Anabilim Dalı, Diyarbakır, Türkiye
Correspondence: Sevcan Arzu Arınkan,
Zeynep Kamil Kadın Doğum ve Çocuk Hast. Eğit. ve Araşt. Hast. Perinatoloji Bölümü,İstanbul Email: Pataraa96@gmail.com
Received: 06.03.2013, Accepted: 03.05.2013
Copyright © JCEI / Journal of Clinical and Experimental Invesgaons 2013, All rights reserved
JCEI / 2013; 4 (2): 141-147
Journal of Clinical and Experimental Invesgaons doi: 10.5799/ahinjs.01.2013.02.0254
RESEARCH ARTICLE
Evaluaon of fetal ventriculomegaly
Fetal ventrikülomegalinin değerlendirilmesi
Özgür Aydın1, Nazan Tarhan1, Sevcan Arzu Arınkan1, Öykü Tosun2, Yusuf Çakmak3,
Abdulkadir Turgut4, Vedat Dayıcıoğlu1
ÖZET
Amaç: Fetal ventrikülomegali tanısı alan olguların prena-
tal, postnatal dönem takip ve tedavi sonuçlarını değerlen-
dirmektir.
Yöntemler: Lateral ventrikül boyutu 10mm ve üzerinde
olan olgular çalışmaya dahil edildi. Toplam 69 olgu sap-
tadık ancak bu olgulardan sekizi çalışmamıza katılmayı
reddetti. Hastalar ek anomalisi olanlar (kombine ventri-
külomegali) ve olmayanlar (izole ventrikülomegali) olarak
2 gruba ayrıldı. Her grup lateral ventrikül boyutuna göre;
haf (10-12mm), orta (12,1-14,9 mm), ağır (15 mm ve
üzeri) ventrikülomegali olarak alt gruplara ayrıldı.
Bulgular: İzole ve kombine ventrikülomegalisi olan 10
fetus doğumdan sonra öldü. Onhastaya cerrahi tedavi
uygulandı. Hastaların %16.7’sine kromozomal analiz ya-
pıldı. Kombine ventrikülomegalisi olan grupta sezaryen
oranı yüksek bulundu(%91.7) ve bu gruptaki hastaların
tümü Yenidoğan Yoğun Bakım Ünitesi’ne (YYBÜ) yatış
gerektirdi. İzole ventrikülomegalisi olan grupta vaginal
doğum daha yüksek bulundu(%45.7).
İzole ventrikülomegalisi olan grupta 18 olgu (%78.3) 6.
ayda normal nörolojik gelişim gösterirken kombine vent-
rikülomegalisi olan grupta hiçbir hastada 6. ayda normal
nörolojik gelişim izlenmedi. Ağır ventrikülomegalisi olan
grupta terminasyon oranı (%64.7) izole ventrikülomegalisi
olan gruptan (%11) daha yüksek bulundu. Haf ventrikü-
lomegalisi olan grupta sağ kalım %90 ve ağır ventrikülo-
megalisi olan grupta %42.9 olarak saptandı.
Sonuç: Ağır ventrikülomegalisi olanlarda terminasyon
oranı; haf ve orta ventrikülomegalisi olan gruplardan
daha sık gözlendi. Bunun nedeni ağır ventrikülomegalisi
olan hastalarda prognozun çok daha kötü olmasıdır. İnt-
rauterin fetal haf izole ventrikülomegalisi olan olgularda
prognoz oldukça iyi olduğundan terminasyon kararının
hasta ile iyice irdelenmesi gerektiğini düşünmekteyiz.
Anahtar kelimeler: Prenatal tanı, büyüme ve gelişme,
prognoz
ABSTRACT
Objective: To evaluate the prenatal and postnatal follow
up, treatment and the outcome of the patients with ven-
triculomegaly.
Methods: Patients with lateral cerebral ventricle size
10mm and higher were included. 69 patients were con-
sidered but 8 patients refused to join our study. The pa-
tients were divided into two groups as they had additional
anomalies (combined ventriculomegaly) or not (isolated
ventriculomegaly). Each group was divided into three
subgroups according to their lateral cerebral ventricle size
as mild (10-12 mm), moderate (12.1-4.9 mm), severe (15
mm and more) ventriculomegaly.
Results: 10 fetuses with isolated ventriculomegaly and
combined ventriculomegaly died after birth. Neurosurgi-
cal operations were performed for ten patients. We per-
formed chromosomal analysis for 16.7% of our patients.
Caesarian delivery was higher (91.7%) in combined ven-
triculomegaly groups and all newborns went to NNICU. In
isolated ventriculomegaly group 18 patients showed nor-
mal neurological development at sixth month. None of the
patients with combined ventriculomegaly group showed
normal neurological development at sixth month. In se-
vere ventriculomegaly group termination ratio was higher
(64.7%) than isolated ventriculomegaly group (11%). The
survival rate was 90% in mild ventriculomegaly group and
42.9% in severe ventriculomegaly group.
Conclusion: Termination is more often in isolated severe
ventriculomegaly than mild and moderate ventriculomeg-
aly group because the prognosis is worse. Because the
prognosis of the patients with mild ventriculomegaly is
good decision for termination will be well evaluated with
the family. J Clin Exp Invest 2013; 4 (2): 141-147
Key words: Prenatal diagnosis, growth & development,
prognosis
Aydın et al. Fetal ventriculomegaly
142
J Clin Exp Invest www.jceionline.org Vol 4, No 2, June 2013
INTRODUCTION
Ventriculomegaly, a nonspecic dilatation of later-
al cerebral ventricles, is the most common central
nervous system (CNS) abnormality identied with
prenatal imaging techniques [1]. The incidence of
ventriculomegaly is around 1per 1000 live births [2-
3].Ventriculomegaly is described as measuring the
cerebral ventricle atrial sizes 10 mm and greater.
Ventriculomegaly is divided into two groups: com-
bined or isolated according to additional abnormali-
ties and is divided in to three subgroups according
to ventricle size; mild, moderate, severe [8].
Today the outcome of pre- or post-natal ventric-
ulomegaly becomes important because the number
of patients with ventriculomegaly increased. Prog-
nosis cannot be determined accurately, since post-
natal outcomes of the patients with ventriculomeg-
aly varies widely [4-8]. The prognosis is remarkably
affected from the additional anomalies and ventricle
size [9]. Ventriculomegaly is usually seen with other
chromosomal or CNS abnormalities. However, it
can be seen because of intrauterine TORCH in-
fections. Detailed USG examination must be done
for ventriculomegaly in order to determine the ad-
ditional abnormalities. Fetal ECHO must be done to
examine congenital heart abnormalities. Fetal chro-
mosomal analysis for chromosomal abnormalities
and tests for congenital infections must be done.
Fetal MRI is suggested for the patients of which
ventriculomegaly is detected on second level USG
(10-12]. Fetal MRI is more sensitive than USG in
determining CNS abnormalities. The mortality and
morbidity have decreased because of the improve-
ments in treatments of children with ventriculomeg-
aly. The better conditions of neonatal intensive care
units contribute this as well. The most important
mortality reason in ventriculomegaly is additional
abnormalities. The most frequent problems that
are seen in surgical treatments are infections and
blocked shunts.
The aim of this study is to evaluate the follow-
up and the treatment of the patients who was diag-
nosed as ventriculomegaly in our center.
METHODS
The study performed prospectively between March
2007 to April 2008 in Zeynep Kamil Obstetrics and
Gynecology Training and Research Hospital. In-
formed consent for participation to study were taken
from all patients and ethics committee approval
from the local ethic committee. The patients who
were diagnosed ventriculomegaly on ultrasono-
grac examination in our center or referred from
the other centers were included to the study. Sixty
nine patients with ventriculomegaly were eligible for
the study. Eight patients were excluded because
of their refusal to join the study. The patients with
cerebral ventricular atrium sizes 10 mm or greater
were included to the study. The patients were di-
vided into two groups as they had ventriculomegaly
accompanied by other anomalies or isolated ven-
triculomegaly. Each group was divided into three
subgroups according to their lateral ventricle sizes
as mild ventriculomegaly [10-12 mm), moderate
ventriculomegaly (12.1-14.9 mm) and severe ven-
triculomegaly (15 mm and higher).
In medical records, maternal age, number of
pregnancy, number of birth, number of abortion,
and previously affected child with congenital malfor-
mations were evaluated. Relevant data were also
evaluated such as, rst and/or second trimesters’
scanning tests, detailed USGs, fetal Echocardiog-
raphy (ECHO), chromosomal analyses, Magnetic
Resonance Imaging (MRIs) if available, pregnancy
terminations were investigated. We evaluated ven-
triculomegaly by serial USG measurements of the
pregnancies, which were not terminated. The pa-
tients with severe ventriculomegaly were referred
Neurosurgery Department. The documents about
babies included: gestation weeks, 1. and 5. minute
APGAR scores, birth weights, genders, additional
malformations, Neonatal İntensive Care Unit (NNI-
CU) acceptations. We inquired the patients whether
they had been an operation or not after birth. For
assessment of neurological development we used
Brunet-Lezine Test in rst 30 days and Denver De-
velopment Test at sixth month. We followed the pa-
tients postnatal 6 to 13 months. The mortality and
morbidity rates were evaluated.
Our evaluation principle on ventriculomegaly
on continuation of pregnancy was depend on the
criterion below;
1. The types; Isolated or combined
2. The gestational age that we determine
3. The severity of ventriculomegaly
4. The parents’ choice
When termination was suggested, the patient
was referred to the academic committee to inform
the parents about the condition. In some cases a
Neurosurgeon and Neurologist were included in the
committee.
In this study statistical analysis have been done
by packet program of NCSS 2007. In assessment of
the documents we used variation analysis besides
denition statistical methods, in comparisons of the
Aydın et al. Fetal ventriculomegaly 143
J Clin Exp Invest www.jceionline.org Vol 4, No 2, June 2013
subgroups we used Tukey multi comparing test, to
compare two groups we used student t test, to com-
pare the qualitative documents we used Chi-square
test. In results, sensitivity was evaluated on p<0.05
level.
RESULTS
Our study has been done with 61 patients. Twenty-
seven of 61 patients (43%) were isolated ventriculo-
megaly, where 34 with (53%) combined ventriculo-
megaly. When we classied the patients according
to their lateral ventricle size we found; 25 cases
(41%) mild ventriculomegaly, 4 cases (6.6%) mod-
erate ven-triculomegaly and 32 cases severe ven-
triculomegaly. In two patients, karyotype analyses
showed trisomy 21 and in 1 triploidi (69XXX). There
was no statistical difference about median age,
pregnancy number, abortion number between iso-
lated and combined ventriculomegaly (Table 1). In
isolated ventriculomegaly and in combined ventric-
ulomegaly groups demographic and obstetric pa-
rameters are present in table 1 (Table 1). There was
no statistical difference about termination time and
NNICU acceptance interval be-tween isolated and
combined ventriculomegaly groups (Table 1). The
initial ventricle size was found sta-tistically higher
in combined ventriculomegaly group than isolated
ventriculomegaly group (p=0.001, p=0.03) (Table
1). Ventriculomegaly determining time, gestational
age at the time of delivery, 1. and 5. minute ap-
gar scores, birth weight medians were statistically
higher in isolated ventriculomegaly group (p=0.020,
p=0.049, p=0.0001, p=0.03) (Table 1).
Table 1. The qualitative documents about isolated and combined ventriculomegaly groups
İsolated ventriculomegaly Combined ventriculomegaly P
Age (years) 27.63±4.88 25.56±5.03 0. 111
Gravidity (2) 2.3±1.54 (1) 1.79±1.07 0.138
Parity (1) 1.07±1.33 (0) 0.59±0.86 0.089
Number of babies alive (1) 0.96±1.13 (0) 0.56±0.82 0. 111
Abortion (0) 0.19±0.4 (0) 0.21±0.54 0.868
First LVG right (mm) 13.05±4.29 17.51±5.23 0.001
First LVG left (mm) 14.25±6.33 18.49±5.84 0.03
Ventriculomegaly
determination time
25.81H 2.67 G ±4.67H 2.22 G
26 H 2 G
22.76H 2.62 G ±5.17H 2.32G
22 H 2.5 G 0.020
Termination time 22.67H 1.67 G ±3.06H 1.15 G
22 H 1G
21.14 H 3.18 G±3.14 H 1.71 G
22 H 3 G 0.435
Birth time 38.75H 2.88G±1.45H 2.01G
39 H 3 G
34.5H 3.42 G±10.16 H 2.43 G
38 H 4.5 G 0.049
1.minute Apgar 7.04±1.57 3.67±2.53 0.0001
5.minute Apgar 8.67±0.7 5.67±2.53 0.0001
Birth weight (gram) 3130.83±605.53 2581.67±728.96 0.037
NNICU internation period 38.67±32.44 17.5±27.24 0.163
In combined ventriculomegaly the number of
severe ventriculomegaly was higher where as in
isolated ventriculomegaly the number of mild ven-
triculomegaly was higher. The termination rate was
higher in combined ventriculomegaly group (64.7%).
Caesarian delivery was statistically high in
combined ventriculomegaly group (91.7%) and
all newborns were admitted to NNICU. There was
no statistically difference about sex between two
groups.
Two of 24 patients (8.3%) died in isolated ven-
triculomegaly group and 8 of 12 patients (66.7%)
died in combined ventriculomegaly group. In iso-
lated ventriculomegaly group 4 patients (16.7%)
had neurosurgical operation, in combined ventricu-
lomegaly 6 patients (50%) had neurosurgical opera-
tion. In isolated ventriculomegaly group, 18 patients
(78.3%) normal neurologically development at 6th
month. None of the patients with combined ventric-
ulomegaly group showed neurologically develop-
ment at 6th month (Table 2).
Aydın et al. Fetal ventriculomegaly
144
J Clin Exp Invest www.jceionline.org Vol 4, No 2, June 2013
In severe ventriculomegaly group the termi-
nation rate was statistically higher. The additional
abnormality rate (combined ventriculomegaly) was
found statistically higher in severe ventriculomegaly
group than mild and moderate groups (Table 3).
There was no statistically difference about sex be-
tween mild, moderate and severe ventriculomegaly
groups (p=0.188). All of the 14 patients with severe
ventriculomegaly went to CCINU (Table 3).
Postnatal surgery rate was found statistically
higher in severe ventriculomegaly groups (p=0.001).
Only 9 of 14 patients (63.7%) had surgery. The oth-
er cases have not been treated surgically because
they died in early postnatal period or because they
were not suitable for surgery. In mild ventriculomeg-
aly group the neurologic decit rate postnatal and
six month was found statistically lower than the oth-
ers (p=0.006, p=0.002). At sixth month 16 patients
(88.9%) in mild ventriculomegaly group showed nor-
mal neurological development but there was no pa-
tient in severe ventriculomegaly group that showed
normal neurological development. The mortality
was statistically higher in severe ventriculomegaly
group. The survival rate was 42.9% in severe ven-
triculomegaly group. The survival rate was 90% in
mild ventriculomegaly group (Table 4). Lateral ven-
tricle sizes of 2 patients which died after birth were
progressively increased through their pregnancies.
In mild ventriculomegaly group the patient with se-
vere neurological decit stayed in NNICU for a long
time and metabolic disease was found through this
period.
Table 2. The postnatal prognosis
of babies with ventriculomegaly Isolated
ventriculomegaly
Combined
ventriculomegaly
Postnatal No 20 83.3% 6 50.0% 0.035
surgery Ye s 4 16.7% 6 50.0%
Postnatal No 22 91.7% 9 75.0%
anomaly Yes 28.3% 3 25.0% 0.173
Exitus No 22 91.7% 4 33.3% <0.001
Yes 28.3% 8 66.7%
Postnatal Normal 20 83.3% 3 25.0%
neurological Mild 1 4.2% 4 33.3% 0.001
decits Moderate 28.3% 0 0.0%
Sever 1 4.2% 5 41.7%
6th Month Normal 18 78.3% 0 0.0%
neurological Mild 28.7% 1 20.0% 0.002
decits Moderate 0.0% 240.0%
Severe 3 13.0% 240.0%
Table 3. The prenatal follow up outcomes when grouped according to lateral ventricle size
Mild
ventriculomegaly
Moderate
ventriculomegaly
Severe
ventriculomegaly
Groups İsolated Group 18 72.0% 250.0% 7 21.9% 0.001
Combined Group 7 28.0% 250.0% 25 78.1%
Termination No 20 80.0% 250.0% 14 43.8% 0.021
Yes 5 20.0% 250.0% 18 56.3%
Birth type C/S 12 60.0% 0 0.0% 12 85.7% 0.035
NSD 8 40.0% 2100.0% 214.3%
Gender Male 11 55.0% 2100.0% 5 35.7% 0.188
Female 9 45.0% 0 0.0% 9 64.3%
NNICU No 16 80.0% 2100.0% 0 0.0% <0.001
Yes 4 20.0% 0 0.0% 14 100.0%
Aydın et al. Fetal ventriculomegaly 145
J Clin Exp Invest www.jceionline.org Vol 4, No 2, June 2013
Table 4. The postnatal prognosis when classied according to lateral ventricle size
Mild
ventriculomegaly
Moderate
ventriculomegaly
Severe
ventriculomegaly P
Postnatal No 19 95.0% 2100.0% 5 35.7% <0.001
surgery Yes 1 5.0% 0 0.0% 9 64.3%
Postnatal No 19 95.0% 2100.0% 10 71.4% 0.124
anomaly Yes 1 5.0% 0 0.0% 4 28.6%
Postnatal Normal 18 90.0% 2100.0% 3 21.4%
neurological Mild 1 5.0% 0 0.0% 4 28.6% 0.006
decits Moderate 0 0.0% 0 0.0% 214.3%
Severe 1 5.0% 0 0.0% 5 35.7%
6th Month Normal 16 88.9% 2100.0% 0 0.0%
neurological Mild 1 5.6% 0 0.0% 225.0% 0.002
decits Moderate 0 0.0% 0 0.0% 225.0%
Severe 1 5.6% 0 0.0% 4 50.0%
Exitus +/- No 18 90.0% 2100.0% 6 42.9% 0.007
Yes 210.0% 0 0.0% 8 57.1%
than mild and moderate ventriculomegaly because
the prognosis is worse.
The isolated ventriculomegaly rate was detect-
ed as 50% in studies reported previously [12-15]. In
our study isolated ventriculomegaly was found 43%
has similar rations to recent studies. We classied
the patients according to lateral ventricle size mild
ventriculomegaly was 41%, severe ventriculomega-
ly was 52.5% and moderate ventriculomegaly was
6.6%. In the study of Gaglioti et al they found mild
ventriculomegaly 43%, severe ventriculomegaly
34% [8]. When we compare our study with Gaglioti
et al the mild ventriculomegaly rate is similar but se-
vere ventriculomegaly rate is higher.
The initial ventriculomegaly determining time
was statistically high in isolated ventriculomegaly
group. We can determine isolated ventriculomegaly
contributed to aquaductal stenosis in 2. or 3. trimes-
ter and this can be cause of this difference. In com-
bined ventriculomegaly the initial lateral ventricle
size the time of diagnosis was statistically higher
from isolated ventriculomegaly group. This differ-
ence is because the diagnosis of isolated ventricu-
lomegaly increased in last years [8,12,15,16].
Termination rate was statistically high in com-
bined ventriculomegaly group. Parents chose the
termination because of poor prognosis, termination
rate in combined ventriculomegaly changes be-
tween 50%-80% in different studies.
Pregnancies with hydrocephalus may be ter-
minated by C/S or vaginal route. For vaginal route
fetus must be in vertex presentation and head cir-
Seven patients (70%) of 10 patients who had
surgery after birth is still alive. 76.9% normal neu-
rological development was found for these patients
after birth. At sixth month severe neurological im-
pairment was 44%, mild impairment was 33%. In
all patients shunt treatment as a surgical treatment
was performed in rst sixth month after birth.
The lateral ventricle size of 9 patients (45%)
among 20 patients stayed still through pregnancy.
In 3 patients lateral ventricle size increased through
pregnancy; there was moderate ventriculomegaly in
one (5%) and there was severe ventriculomegaly in
two patients (10%). The lateral ventricle size stayed
xed in 2 of 4 patients with moderate ventriculo-
megaly and in 1 patient ventriculomegaly resolved
and become mild ventriculomegaly. In one patient
lateral ventricle size increased and become severe
ventriculomegaly. None of the patients with severe
ventriculomegaly resolved.
DISCUSSION
Nowadays congenital malformation can be deter-
mined more often because of the improvements in
prenatal diagnostic methods. Ventriculomegaly is
the most frequent malformation that can be deter-
mined prenatally. Because of the practitioners be-
come more interested in ventriculomegaly follow up
and treatment. In combined ventriculomegaly be-
cause of the high mortality and morbidity rates par-
ents must be informed about this condition before
viability limit if they decide termination. Termination
is more often in isolated severe ventriculomegaly
Aydın et al. Fetal ventriculomegaly
146
J Clin Exp Invest www.jceionline.org Vol 4, No 2, June 2013
cumference must be not over 2 SD for that age. If
the parents don’t want caesarean delivery and the
hydrocephalus is with very poor prognosis (alobar
haloprosencephalus, hydrancephalia) rst cephalo-
synthesis may be performed before vaginal deliv-
ery. In our hospital we give decisions to continue
or terminate the pregnancy by evaluating the ges-
tational age, severity of ventriculomegaly and the
parents’ choice. If termination is wanted, rst it is
evaluated in the Academic Council then the parents
are informed.
If necessary, a neurosurgeon and Neurologist
participate in the council. In the literature there is
not evidence about the criteria for termination. In
combined ventriculomegaly group caesarean deliv-
ery is statistically high. It may be related to the addi-
tional abnormalities and the higher head the normal
circumference. And there are studies that show the
prognosis is better with caesarean delivery.
Postnatal survival rate and normal neurologi-
cal development rate at six month were statisti-
cally higher in isolated ventriculomegaly group. In
a meta-analyses about isolated ventriculomegaly
30 studies were included and the survival rate was
found as 92.7% and where as normal neurological
development was found 85% [15]. Postnatal sur-
gery was lower in isolated ventriculomegaly [20].
Because, mild ventriculomegaly showed normal fol-
low up documents postnataly.
In mild ventriculomegaly group the fetuses with
additional abnormalities was terminated because of
the multiple malformations and chromosomal ab-
normalities. In mild isolated ventriculomegaly group
the survival rate was 90%, postnatal normal neu-
rological development was 90% and normal neuro-
logical development at sixth month was 88.9%. Ga-
glioti et al reported that the survival rate in isolated
mild ventriculomegaly 97.7% and normal neurologi-
cal development 93% [8]. Signorelli et al reported
that 100% normal neurological development rate
and Pilu et al 96.2% [17,18].
In this study chromosomal analysis was per-
formed on 16.7% of the patients (10 cases). There
was chromosomal abnormality in 3 cases (5%).
Pietro et al reported incidence of aneuploidies
is high (15%) when severe or borderline ventriculo-
megaly is associated with additional abnormalities
[10].In a review of Melchiorre et al chromosomal
abnormality rate was found 2.8% [11]. For the pa-
tients with isolated ventriculomegaly chromosomal
analysis will be advised for only carefully selected
phenomenon. Much more chromosomal analysis
must be done for the patients with ventriculomegaly.
There was severe neurological decit in 4 cases
(44.4%), mild decit in 3 cases (33.3%). The mortal-
ity rate after surgical treatment was found 10.2-50%
and normal neurological development rate was
found 33-59% in the recent studies [20-22].
In our study mortality rate seems to be normal
when compared with other studies. But morbidity
rate was higher than the other studies [20-22].The
reason for this can be the low social and economic
conditions of the families.
As a result, termination rate was clearly lower
in isolated ventriculomegaly. Because of the good
prognosis continuation of the pregnancy is advis-
able (especially in isolated ventriculomegaly). But
these cases may progress during the perinatal pe-
riod. For this reason, we must remember neurologi-
cal decit can develop although lateral ventricle size
does not increase.
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